Using Medical Necessity to Improve Client Outcomes

1. Using Medical Necessity to Improve Client Outcomes Jason Hess, LCAC Executive Director Heartland RADAC

2. Alternative Title How do I get those darned insurance companies to listen?!?

3. 4 Essential Elements to Good Counseling WEG + • Warmth – Caring, Supportive, Welcoming • Empathy – Understanding, Responsiveness • Genuineness – Heartfelt, Sincere, Natural • The ability to tell everything you know about your client to a complete stranger who has never seen and never will see them in a clear, consistent manner using absolutely no jargon whatsoever while insuring there is a complete plan for the whole person that includes how they will manage their medical, mental health, housing, and employment issues all the while believing that the other person has no interest in the wellbeing of the person you are looking at across your desk

4. What we all learned in school

5. What is our work??? • Understanding Systems and Recovery Oriented Systems of Care (ROSC) • Helping people accomplish their goals • Bridging • Teaching • Not Assuming ANYTHING!!!

6. “As for the future, your task is not to foresee it, but to enable it.” Antoine de Saint Exupery

7. What is Medical Necessity Medicare defines it as: Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice

8. What is Medical Necessity A general definition of medical necessity is: • Services requested are needed to identify or treat an illness that has been diagnosed or suspected. • Treatment services are consistent with: • the diagnosis and treatment of the condition (‘experimental treatments’ are disallowed) • the standards of good medical practice • Treatment services required are for other than convenience. Public Policy Statement on Managed Care, Addiction Medicine and Parity: Supplement for Physicians and Others on the Step-by-step Utilization Review Process

9. Why do we need to consider Medical Necessity • Defines observed conditions and problems • Determines level of treatment need • Provides a method of communication between service providers • Gives information to Managed Care Organizations for Utilization review • IT ALLOWS TREATING PROVIDERS TO GET PAID!!!

10. How is Medical Necessity Determined? Medical necessity starts with a solid assessment of an individual’s need and applying it to specific criteria designed to guide an individual into the most clinically appropriate level of care.

11. When do we need to think about Medical Necessity? All the time!!!

12. Assessment • Observation of behaviors • Clinical Interview • Collateral information • Secondary Testing • Diagnosis

13. Assessment is an ongoing process that is PART of treatment, not simply an activity that determines treatment. P l a c e m e n t Assessment Variables Client Preference Diagnosis Course of Illness Prior Treatment Response Family History Mental Status Matching Variables Intoxication/Withdrawal Biomedical Conditions Emotional/Behavioral Conditions Change Readiness Relapse Potential Environmental Conditions Modifying Variables Age Gender Sexual Orientation Culture/Language/Ethnicity Service Availability Childcare / Eldercare

14. Secondary Assessment Tools - Examples SASSI- Substance Abuse Subtle Screening Inventory • Paper/Pencil • Spanish Version • Cost AUDIT – Alcohol Use Disorders Identification Test • Oral or paper/Pencil • Multiple Languages • Public Domain CAGE-AID • Oral or paper/pencil • Multiple Languages • Public Domain

15. Secondary Assessment Tools – Cont. DAST – Drug Abuse Screening Test • Oral or paper/pencil • Reproduce with author credit CRAFFT • Adolescents • Oral or paper/pencil • Public Domain MAST– Michigan Alcoholism Screening Test • Oral or paper/pencil • Public Domain

16. Secondary Assessment Tools – Resource For additional information specific to substance use (and other) assessment tools: http://lib.adai.washington.edu/instruments

17. Recognized Criteria - Kansas Kansas recognizes and mandates the use of the Patient Placement Criteria published by the American Society of Addiction Medicine for the following populations: • Those eligible for Federal Block Grant funding • Medicaid recipients • DUI Evaluations

18. ASAM Patient Placement Criteria Guides Assessment across 6 Dimensions • Acute Intoxication and/or Withdrawal – Assesses the need for stabilization of acute intoxication. • Biomedical Conditions & Complications – Assesses the need for physical health services • Emotional, Behavioral, or Cognitive Conditions & Complications – Assesses the need for mental health services. • Readiness to Change – Assesses the degree of need for motivational enhancement services to engage a person and begin a recovery process. • Relapse, Continued Use, or Continued Problem Potential – Assesses the need for relapse prevention services. • Recovery/Living Environment – Assesses the need for specific individualized family or significant other support and services. Source: Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013.

19. Using Criteria to Assess Need Criteria Are Not … Criteria Are … a method of communication to engage people into treatment and the recovery process a way to communicate with a client about next steps in their care a guide to look at an individual’s situation in a holistic manner a guide to assist a client in moving through the continuum of care a way to communicate with payer sources about the needs of their members • a cookbook or checklist • a substitute for clinical judgement • a determination of length of stay • a way to just start a client in treatment

20. Documenting Medical Necessity Key Components of Documentation: • Multi-Dimensional – Assess across all parts of an individual’s life. • Clear documentation related to the presenting problem. • Answer the phrase “As evidenced by . . . “ • Specify the intended interventions and/or referrals

21. “As Evidenced By…”

23. Continuum of Care • Network of Treatment Services • Network of Treatment Providers • Meets individual’s changing needs • Includes clinical and non-clinical modalities • Recovery Oriented Systems of Care (ROSC)

24. Levels of CareKansas currently licenses treatment programs to provide the following modalities of care: • Assessment and Referral • Level 0.5 – Early Intervention • At-Risk Individuals who do not meet diagnostic criteria for substance use disorder • Level 1 – Outpatient • Less than 9 hours of service per week • Level 2.1 – Intensive Outpatient • 9 hours or more of service per week

25. Levels of Care – Cont. • Level 3.1 – Reintegration • 24 hour structure with at least 3 hours per week of alcohol and drug specific counseling • Level 3.3 (Adult) & 3.5 (Adolescent) – Intermediate • 24-hour residential care • Level 3.2-WM – Social Detox • Withdrawal Management in a 24-hour support setting

26. Moving through the treatment Continuum Should Not… Should… Include input from the client Depend on the client’s ongoing need through multidimensional assessment Match a client’s specific needs Provide service at the least restrictive level of care that is safe • Be based on time spent in treatment • Depend on the number of goals completed • Be determined without input from the client • Be made by a non-clinical system

27. HELP!!! What should I write down so a Care Manager (or anyone else for that matter) will understand my client’s needs?!?! Remember . . . • You are painting a picture of an individual’s need • You are communicating with someone who will neither see nor speak to the client about whom you are referring – DON’T ASSUME ANYTHING • Be specific, present observable behaviors and quotations • Complete the phrase “As Evidenced By . . . “ • Include a multidimensional assessment • Specify the medically/clinically necessary service types • What goals will the client be working toward achieving?

28. Service/Treatment/Recovery Planning “If you don't know where you are going, you'll end up someplace else.” Yogi Berra

29. SMART Treatment Planning Specific – What exactly is the outcome I will achieve? Measurable – How will I know when I’ve achieved this goal? Achievable – Is my goal realistic? Can it be accomplished? Relevant – Will the goal help me achieve what I ultimately want? Time limited – When can I expect to have achieved this goal?

30. Client Driven • What does the client want to accomplish? • Written in client’s words • Clinical guidance is necessary to connect desires/wants to the problem being addressed. • Celebrate accomplishments and create the opportunity for new achievements. • Plan should result in an inventory of achievements

31. Discharge/Transition Planning • Answers the question “If services were not available to you after today what needs to be in place so you can make change?” • Begins at Admission • Identifies the Recovery Oriented Systems of Care (ROSC) • Plans for community based recovery

32. The End